A fair warning to all of my readers up front: this blog post is obviously going to have a gentle biased undertone to it, so as much as I want to encourage students to go PA, I also want to encourage students to visit other NP and MD blogs to get their perspective on this topic. This post is going to be short and sweet. You already know what a PA is from my latest post. So what's the difference between a PA vs. a nurse practitioner (NP) vs. a physician (MD)? This question is so common amongst high schoolers and undergraduate students who are trying to decide on a career path best suited for them. I'm asked about the PA vs. NP question the most given that they are both considered "mid-level providers" (an often cringe-worthy term that's almost never used verbally in practice). But it's true, we ARE mid-level providers. There are so many similarities between the three from taking a medical history to completing a physical exam to ordering diagnostic tests to coming up with an appropriate diagnosis and treatment plan to prescribing medications, that often times patients can hardly tell who is who. It's the key differences that I want to focus on throughout this post to help my readers make an educated decision. And if you're not pre-PA and you just find yourself reading my blog for fun/to keep up, I think it's equally as important to shed light, educate, and bring awareness to the general public on what it is that separates the three. You just never know when you or a loved one could end up as the patient, and it's nice to know the role of each medical provider on your treatment team. It's also so important to keep in mind that there are good and bad PAs, MDs, and NPs. Don't let one provider ruin your image of an entire group of providers. At the end of the day, all providers share a common goal with one another: to ensure high-quality care, safety, and life longevity to patients. Here are the reasons why I personally went PA:
NPs are trained through a nursing model. The nursing model was first established by Stockwell in 1985 and he defined this model as "a simplified way of organizing a complex phenomenon". The nursing model focuses on the patient. It's very practical. You look at the patient's mental, emotional and physical needs at present. You look at the patient in a cyclical way: assessing the patient's individuality, planning to treat and prevent recurrence, implementing plans and setting goals, and evaluating care to analyze where improvements can be made. There are a lot of benefits to looking at the whole patient and not just the disease. You look at holistic treatments, alternative medicine, nutrition, health, and wellness. You look at the patient's ability to perform activities of daily living (breathing, eating, drinking, sleeping, communicating, going to the bathroom), the patient's life span, the level of dependence on others to survive, the biologic, psychological, sociocultural, environmental, and politicoeconomic factors, and the patient's individuality. Both PAs and MDs are trained through a medical model. The medical model dissects disease processes into their most intimate layers. You look at the pathology, what the cells, the tissues, the muscles, and the bones look like under a microscope, both normally and abnormally. You look at the complex anatomy and the detailed physiology of all body systems, in addition to the pathophysiology (seeking to understand physiological process development and future progression). You look at the biochemical pathways of hormones, neurotransmitters, regulatory mechanisms, and molecular properties. You look at clinical medicine and how the patient presents in terms of signs, symptoms, and physical exam findings. You look at the pharmacology, not just what to give a patient or how to administer it, but why, why one specific antibiotic is preferable to another for a particular microorganism. The medical model uses an evidence-based approach to treatment, which means providers are constantly learning and adapting to new research trials. For these reasons, I find that the medical model allows PAs and MDs to have a deeper understanding of physiologic mechanisms and pathologic aspects of medicine. From my experience thus far, I have found that this background knowledge allows PAs and MDs to provide a better description of disease processes to their patients.
NPs can get a doctorate level degree. NPs first earn a 4 year BSN (bachelor of science in nursing) degree where they cover anatomy, physiology, patient health assessment, basic pharmacology, basic pathophysiology, stage of life care, and supervised clinical rotations. They then take a national licensure examination (NCLEX-RN) to become a registered nurse (RN). Aspiring NPs then must gain 1-2 years of experience as an RN in the specialty of their choice. After gaining that experience, they can go on to a 1-3 year long master's degree program (depending on the specialty) and apply for certification to become an NP. NPs also always have the option to move into administration, organizational leadership, nursing informatics, health care policy, teaching, or medical research. So where does the DNP title come into play? There are several different types of programs and paths to get there, which is what I think people find most confusing. Here's my attempt to explain it. There are accelerated BSN to DNP programs that are approximately 65-95 credits + 1,000 clinical hours. This can take 3-4 years to earn either a DNP or sometimes an MSN/DNP dual degree. These programs often require a bridge year or an additional non-nursing bachelor's degree to qualify for this route. There are also MSN to DNP programs that are approximately 33-43 credits + 500 clinical hours (+500 hours from the BSN). This can take 1-2 years to complete. It's also important to know that there are part-time options (not uncommon amongst already working RNs) and full-time options, which drastically changes the length of time to earn a degree. In contrast, PAs obtain a 4 year bachelor's degree in a major of their choosing and attend a 2-3 year PA program. It can definitely be discouraging at times that other professions like physical therapists, for example, are granted a doctorate level degree. You put in the same, if not more, credits and clinical hours for a master's level degree. But at the same time, students would not have chosen a PA career if they really cared about the Dr. title before and after your name. Doctorate level PA programs have been a discussion topic highly debated for years, but honestly I believe it would just cause a lot of confusion in the work place for both providers and patients who are just finally starting to understand our current role as a mid-level provider.
NPs must work as a registered nurse first. PAs can start their training straight out of college, however most PA programs require hours of patient care experience, so this is really more of a similarity than a difference. And don't get me wrong, there is a definite benefit to working and earning some money/ gaining some real life experience in between your years of schooling. In comparison, it's ultimately impossible to work during PA school and during undergrad as a biology major, for that matter. So here I am, a poor PA student who hasn't had a job in 7 years, living off my parent's salary. Not ideal. If you're trying to decide between PA vs. NP, I would base your decision on where you are in your schooling. If you are already enrolled in nursing school or are planning on transferring into an accelerated nursing program, NP may be the route for you. If you originally thought you may be pre-med and are currently a biology major (or something along those lines), PA may be a better path for you to follow. The professions are entirely too similar for you to completely swap paths, at this point if you are already on one. Life is too short to waste excess years in school to reach the same goal. And for those of you who are fresh and have not chosen a path yet, it's really all based on if the differences in this post are deal breakers for you and your personal preference.
NPs must specialize in one area of medicine. During their master's/ doctoral degree program, NPs are trained in either family medicine, adult medicine, geriatrics, pediatrics, NICU, anesthesia, psychiatry, or midwifery. PAs are trained in all specialties and can change specialties as they please after graduation. As a result, NPs are more often going into primary care and PAs are more often specializing. 80% of NPs are educated and trained in primary care. PAs have clinical rotations in almost all areas of medicine, whereas NPs only get exposure to other specialties from their clinical rotations as a nursing student. Are you the type of person that wants to go into one field forever? It's really a personal choice. You have to know yourself, your own level of boredom with monotony, and your projected satisfaction.
NPs can open and run their own practice. PAs must practice under the "supervision" of an MD. The term supervision is often misunderstood. If you are just a phone call away from your attending who is in another state, that is considered "supervision". Attendings are not hovering over you as you type every note or see every patient. Just recently in January 2016, legislation was passed by the former governor of NJ to forego MD/DO co-signatures on PA notes. The autonomy is there. With running your own practice also comes a lot of added responsibilities separate from the medicine aspect. If the printer is broken, I personally do not want to be the one to have to fix it or the one to have to hire someone from IT to take care of it. I also prefer the inpatient hospital setting to the outpatient office setting, so owning my own private practice was never a goal of mine.
MDs are independent practitioners. They are the most prestigious of the medical providers by nature. If you are seeking that MD title, the recognition, the specialization, and the autonomy that comes with it, medical school may be the path for you. Your dreams of being like the surgeons on Grey's Anatomy performing once-in-a-lifetime solo surgeries may not be quite as fulfilled if you decide to become a PA.
MDs have to take the MCATs. The MCAT is a 7.5 hour long standardized examination students commonly take during their junior year of college. The exam consists of biology, biochemistry, general chemistry, organic chemistry, physics, psychology, sociology, and critical analysis and reasoning. I've always been a really strong exam taker, but standardized exams are in a whole different category. From NJ ASK to HSPA to the SATs, it's just never been my strong suit. This was a huge deterrent for me. To be completely honest, I did not want to take a review course class every Saturday and spend 7.5 hours every Sunday doing practice exams to try and improve my score or make myself "smarter". I'm a firm believer that intellectual ability is much better measured by four years worth of honorable course grades and grit than a 7.5 hour exam that I had to train myself to be good at. As a side note, since I applied as a 3+3 student, I did not have to take the GRE either and I am proud to say Rutgers is a GRE optional program.
MDs are not required to have patient care experience prior to medical school. Most PA programs require thousands of hours of patient care experience to apply, which more often than not leads to taking a year or more off between college and PA school. Now this may seem like a disadvantage to going the PA route, but I'm pleased to share with you all that's not the case. My classmates and I all came from very different backgrounds with experiences ranging across all fields of medicine prior to school, which added so much character and diversity to my class. Patient care experience tests your ability to handle gruesome scenes and uncomfortable situations, while giving you a front row seat to the health care provider dynamic. I also strongly believe those hours give students the humility necessary to develop into the best version of a PA you can be. I mean how can you fully appreciate where you're at and how far you've come if you haven't started from the bottom. I'll be making a post very soon on some unique ways to gain patient care experience, so stay tuned!
MDs have a significantly longer schooling/ training process. Point blank, I cannot imagine myself signing up for 10+ years of extra schooling and not getting my first real big girl job until I was in my 30s. I felt like I'd just never see the light at the end of the tunnel in medical school, given that just 3 years of PA school seems like a long commitment to my textbooks. My priorities are more family oriented, and working 80 hours per week, taking call, and working the night shift doesn't give me much opportunity to spend time with my future children.
MDs make significantly more money. If the above statement paragraph is true, then it is inevitable (and only fair) that MDs are compensated for such a long life sacrifice. There's not much else to say about that, it's the #1 best paying job in America. In 2017, the average salary of a medical doctor is $294,000 compared to $104,131 for PAs. And if you're considering primary care, the average salary drops to $217,000 compared to specialists making an average of $316,000. Some additional things to factor in concerning money are as follows. Medical school tuition is much higher than PA school. The average in-state PA program tuition is $71,369 for a 3 year program and even less for a 2 year program. If you apply to an accelerated PA program you can sometimes even get undergraduate tuition for your first year of PA school. The average medical school tuition is $207,866 for a public school and $278,455 for a private school. MDs also have to pay for malpractice insurance. The cost of malpractice insurance varies greatly depending on what state you practice in and how high risk your specialty of choice is. In Minnesota in a lower risk specialty you may pay just $4,000 a year. In California in a higher risk specialty you may have to pay $34,000 a year. Most of the time a physician's salary does correlate with these costs. Taking an MCAT review course, applying to medical schools, applying to residencies, and applying to fellowships is expensive between application fees and flight/ hotel costs for out-of-state interviews. The MCAT costs $310 to take. An MCAT review course can cost anywhere from $2,000 for a self-taught course and $4,000 for a private tutor. Every medical school application costs $160 +$38 for every school you want to apply to +$150 for each secondary application + the cost to submit you MCAT scores and official transcripts + $406.15 for interviews +$100 for an acceptance deposit. The average medical student applies to an average of 14 programs and receives an average of 4.5 interviews, which makes the cost to apply to medical school over $8,129. And it doesn't stop there. Applying to residencies and fellowships are even more expensive than applying to medical school. A resident physician only makes an average of $51,000 per year. You also do not start making that $294,000 salary until you're around age 30. And that salary is not just handed to them. MDs are often exceeding 60-80 hours/ week. Remember some of these unspoken numbers when the general public is raving about a physician's salary.
MDs must specialize in one area of medicine. Before starting residency, a decision must be made as to which field of medicine an MD wishes to practice in for the rest of their life. Specialty flexibility is one of the greatest aspects of the PA profession, in my opinion. I did not want to be locked-in to one field of medicine forever, given that as life goes on some schedules are better than others and interests fluctuate. As a PA, I can work in a fast paced ED while I'm young with no children and have a lot of energy. I can pick up per diem shifts or night shifts for extra money as my empty schedule allows. In the same respect, once I have school-aged children, a 9-5pm M-F Dermatology position may be more desirable. I'm not glued to one specialty or one set of hours as I would be with a career as a physician, and that for me is ideal. My mom was a stay-at-home mom while I was a child and as a result, family time is something that's really important to me. And this may not be as much of a priority for others who are more career driven which is just as respectable, but I want balance in my life.
MDs have a lower job satisfaction rate. PAs like what they do. I feel like I have to repeat that. PAs LIKE WHAT THEY DO. Over 96% of PAs would recommend their career path to others. Only 64% of MDs would choose a career as a physician again. One statistic that surprised me most was that family medicine statistics are rather different. 73% of family medicine doctors would choose a career as a physician again. And yet, family medicine docs are one of the lowest paying specialties. This just goes to show you, money doesn't equal happiness. Only 45% of MDs would choose the same specialty again, which again just further proves the value of PA specialty flexibility through life. PAs were ranked the #3 best healthcare job and physicians were ranked the #14 best healthcare job. The rate of burnout for MDs is 37.9% compared to the general public working population at 27.8%. The rate of dissatisfaction with work-life balance is 40.2%, which is almost double when compared to the general public working population at 23.2%. Do what you love and do it for yourself.
MDs are constantly needing to be accepted into the next stage of their career. From medical school, to residency, to fellowships, to board exams, there's a lot of pressure to make it to the next level. In addition, the stress of applying to medical school, then applying to residencies, and then applying to fellowships seemed like a never ending cycle of applications, crossed fingers, and worry. I'm thankful I don't have to worry about scoring high enough on the step1/step2 exams or the medical board exams (written and verbal), and I'm really thankful I don't have to worry about "placing" into my dream specialty. I have the power to choose. Life is too short to spend years of my life studying your second choice specialty. And life is too precious for that many years of high-intensity stress. With that being said, you can't have PAs without MDs, and PAs have the utmost respect for all of the physicians out there in the world who dedicate their entire lives to medicine.
So much for short and sweet, I tried. Choose what you may, & "namaste a PA"…